After a fascinating period of almost 30 years of IVF and 15 years of intracytoplasmic sperm injection (ICSI), it must be admitted that only a small part of the world population benefits from these new reproductive technologies.

Worldwide, more than 80 million couples suffer from infertility; the majority of this population are residents of developing countries (Fathalla 1992). New reproductive technologies are unavailable, scarcely available, or very costly in so far that the large majority of the population cannot afford infertility treatment at all (Van Balen and Gerrits 2001; Nachtigall 2006). Developing countries have a large reservoir of infertility problems, of which bilateral tubal occlusion is the most important one (World Health Organization 1987; Nachtigall 2006), a condition that is potentially treatable by assisted reproductive technologies. Tubal factor infertility, the most common etiological factor in developing countries, is mainly caused by sexually transmitted diseases (STD), postpartum or post-abortal infections, pelvic tuberculosis, and other infectious and parasitic diseases. In most developing countries, reproductive health care is synonymous with family planning and contraception. In developing countries however, infertility and fetal and neonatal death constitute an important public health problem resulting in a high prevalence of childlessness (Bergstrom 1992).

During recent decades, politicians have always shown great interest in reducing the number of births in developing countries, the so-called political “top-down” perspective (Hamberger and Janson 1997), but infertility care received little or no attention. Especially in developing countries, where poverty and infections are commonplace, fertility and fetal care are affected by many different cultural, environmental, and socioeconomic factors. The most cost-effective approach to tackle infertility problems in developing countries is prevention and education (Leke et al. 1993). However, in those cases where prevention has failed, simplified assisted reproduction must be thought of as a valuable option (Malpani and Malpani 1992).

In Egypt, it was previously stated that only 50–60 % of couples could afford to pay for IVF and embryo transfer, induction/monitoring of ovulation, or artificial insemination with husband’s spermatozoa, all of which only the private sector provided. These results demonstrate that prevention of infertility is still the most efficient option in developing countries (Serour et al. 1991a, b).

In recent years, there has been increasing interest in milder approaches to IVF treatment such as minimal ovarian stimulation or natural cycle IVF (NC-IVF). These approaches decrease the physical burden and psychological distress for patients, increase patient convenience, and reduce treatment costs (Devroey et al. 2009; Fauser et al. 2010). NC-IVF is especially attractive because it is completely safe, requires minimal medication, and can be easily repeated over successive cycles. The main drawback of NC-IVF is its low efficiency per cycle, which is partly related to high cancelation rates due to premature LH surge and premature ovulation, detected at the time of oocyte retrieval (Pelinck et al. 2005).

The time has come to incorporate those new insights in a specially designed infertility care program, leading to a cost-effective simplified assisted reproduction program with special attention to avoid ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy, as a valid treatment protocol in developing countries when prevention or alternative methods have failed.

In affluent countries, the situation looks a lot different. Instead of simplifying procedures to reduce costs, complexity is about to increase. The reason is that patients in affluent countries have a completely different profile compared to patients in developing countries. Here the main indication for IVF treatments is advanced age and low ovarian reserve. To treat these highly complex conditions successfully, it is necessary to improve stimulation protocols and IVF laboratory technologies. On the medical site, mild stimulation protocols or modified natural cycle IVF become more and more important. The reason is that older patients will not respond adequately to traditional stimulation protocols using high doses of gonadotropins. Instead of oocyte quantity, the treatment will focus more on oocyte quality.